The pressure and shame of a high risk pregnancy
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.q2784 (Published 22 January 2025) Cite this as: BMJ 2025;388:q2784
Earlier this year I gave birth to a bouncing baby girl, an 8 lb 4 oz bundle of joy. The euphoric moment was made even more special by its contrast with a gruelling pregnancy. This was my third pregnancy but my first experience of following a high risk care pathway. Although I’ve rarely had a body mass index (BMI) below 35, my first two pregnancies managed to slide under the medical radar. This time I was much older, and somewhat fatter, with a BMI of 41. I was referred to a consultant led clinic and assigned to the high risk category.
We know that risk operates on a continuum, but my categorisation as high risk during this pregnancy was entirely binary. It defined me for those nine life changing months. I felt helpless. Even if I had wanted to take action to reduce my weight, no one recommends dieting or a blistering new exercise regimen during pregnancy, with good reason. I was condemned to feel shame, and often anger and resentment, with no way out.
Communicating risk
I started dieting as a pre-teen, but gave up a decade ago because I didn’t want my daughters growing up in a household where dieting was present. I learnt to focus on being healthy in other ways, and to accept my body. But on the high risk pregnancy pathway, this “fat and fit” self image was undermined. I was prescribed a vast array of medications, all with preventive functions. You might think I would have been glad to have these, but in the absence of any symptoms that needed resolving, they served only as a reminder of my unhealthy, at-risk status.
At risk for what, I wondered. The specific negative outcomes were unclear to me, and numerical likelihoods were rarely if ever communicated. Certainly, the risk of me having a big baby was closely scrutinised, but having had two babies already I knew that life with a chunky newborn is significantly easier than with a teeny one. I realised that having a large baby can lead to problems during delivery, but as a 5’11” woman who delivered her first 9 lb 3 oz baby at home, I wasn’t worried. There was talk of percentiles too, but our hospital delivers 600 babies per month. Even being on the 99th centile means six babies that month are similarly sized. We can’t all be average.
Constant monitoring
Doctors never actually told me that if I were thinner, I wouldn’t need to worry about the baby, but they didn’t need to. Society is convinced that weight is under an individual’s control and so the powerful sense that I had brought this on myself—and on to the developing baby—was overwhelming. The health professionals I met never asked about or recognised these feelings. I thought they did not see the heavy stigma that comes with being fat.
It was months later that I came across the acronym BRAIN (Benefits Risks Alternatives Intuition Nothing), a tool to help patients make informed choices. I was struck by my total lack of choice when embarking on the intensive scrutiny which was the defining hallmark of the high risk pregnancy pathway. Fitting an additional 19 appointments into as many weeks simply added to my stress and worry. Overall, the mental health effects of being monitored, measured, and judged were devastating.
What you need to know
Overweight and obese pregnant women can feel a heavy burden of stigma, pressure, and shame
Pregnant women of all sizes need to be reassured and given choices about their care
The experience of a high risk pregnancy care pathway can increase mental health burden, which can also carry negative consequences for mother and baby
Education in practice
How might you ensure that you are helping support someone facing stigma or shame during pregnancy?
What support could you give someone in a high risk pregnancy to help manage the mental burden of additional appointments and monitoring?
Footnotes
Competing interests: none.